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MSc, Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand / Background: Chronic obstructive pulmonary disease (COPD), characterised by progressive airflow limitation which is not fully reversible and associated with pulmonary and systemic inflammatory processes, is largely associated with smoking and is classified as a disease of lifestyle. Other factors related to the incidence of COPD are passive smoking, the inhalation of gases from biomass fuels and the genetic absence of the protease alpha1-antirypsin in some people. COPD is found in all sectors of society and is not dependent on level of income or on the global location of a population. Compounding the incidence of COPD in Africa is the human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) that predisposes patients to the development of COPD. Hydrotherapy has been used since ancient times as a preventative and/or therapeutic form of treatment. Physiotherapists have used hydrotherapy alone or as a useful adjunct to other treatment options for years. Today aquatic therapy is practised in many centres where a multi-disciplinary approach to this form of treatment is offered. There are a number of methodologies of application of the therapy. Among these are Ai Chi, Halliwick, Watsu and Bad Ragaz. The treatment takes place in thermoneutral water between 29 degrees centigrade (oC) and 34oC where use is made of the buoyancy and/or resistance created by the aquatic medium. Musculoskeletal conditions, including pre-operative total hip and knee replacements; osteoarthritis and rheumatoid arthritis can be treated with this modality. Hydrotherapy affords athletes a non-weightbearing rehabilitative environment to enable a quicker recovery and also enables cardiovascular reconditioning to commence sooner than would be afforded by a land-based rehabilitation programme. Many chronic conditions, including cardiac failure, stroke and metabolic disorders have benefited from a hydrotherapy intervention. COPD has been shown to have an inflammatory component. Exercise on land has been shown to have an anti-inflammatory effect in healthy individuals but increased levels of tumour necrosis factor–alpha (TNF-alpha), known to be associated with inflammation, has resulted from moderate intensity land-based exercise in patients with COPD. Aim and objectives of the research: The aim of this study is to systematically review the evidence related to the role of hydrotherapy in the management of patients with COPD. The research objectives of this study are: to determine, from the literature, whether water temperature and depth of immersion influences cardiopulmonary function in patients with COPD; to determine, from the literature, whether hydrotherapy increases endurance, function and quality of life (QoL) in patients with COPD and to determine, from the literature, whether the anti-inflammatory effects of water-based exercise in patients with COPD have been documented. Method: The study design is a qualitative systematic review. A search was made for relevant journal articles in the PUBMED, SCOPUS, CINAHL, MEDLINE, SPORTSDiscus and Cochrane review databases. Google scholar was perused in order to find any grey literature pertaining to the population under review. The review of the literature was from 1996 until 2009. This protracted period of 13 years was needed to insure that all leading articles on the subject under review were included in the review. There were too few articles available from 2000 onwards to produce a valid review of the topic. The words and/or phrases used in the search were: hydrotherapy, Halliwick, Ai Chi, Watsu, Bad Ragaz, chronic obstructive pulmonary disease (COPD), pulmonary rehabilitation, emphysema, chronic bronchitis and the anti-inflammatory effects of exercise. Articles in the form of systematic reviews, randomised controlled trials, clinical trials and case studies pertaining to adult patients with non-acute, non-terminal COPD and the use of hydrotherapy were included in this review. No articles based on animal studies were included. No articles on Kneipp therapy were included as hydrotherapy in this format does not include the immersion of the patient in water. The LOW (Lewis, Olds and Williams, 2007) critical appraisal tool was used to evaluate the articles included in the systematic review. Results: Thirty-seven studies were sourced and nine studies were included in the qualitative systematic review. A total of 35 outcomes measures were reported within the nine included studies. They were of a varied nature and therefore were grouped into the following categories: cardiovascular; pulmonary; muscle strength/weakness; endurance and power, QoL and activities of daily living (ADL). Beneficial results were found in relation to heart rate (HR) with a regime of upper limb exercises performed in water. Following an upper body and upper limb 15 minute land-based exercise programme and subsequent 10-15 minute rest period on land, systolic blood pressure (SBP) was decreased by 14mmHg and diastolic blood pressure (DBP) by 6 mmHg (compared to resting land values) when patients with COPD were immersed in 32 oC water. Ejection fraction (EF) improved significantly at the end of a two month breathing exercise programme in water. A water-based intervention period of 120 minutes (20 minutes, six days/week for two months) decreased left ventricular end –diastolic (LVd) and left ventricular end-systolic (LVs) dimensions (p<0.01). Exhaling into water, during an aquatic breathing exercise regimen lasting 30 minutes/day, six days/week for two months, was demonstrated to significantly increase percentage predicted forced expiratory volume in one second (FEV1%). Arterial concentration of carbon dioxide (PaCO2) levels were decreased significantly due to the breathing exercise with exhalation into water regimens and during the breathing out into water intervention for 20 minute /day for six days the arterial concentration of oxygen (PaO2) levels were increased. Peak flow (PF) was improved in all the breathing programmes where the patient exhaled into water. Improvement in respiratory rate (RR) and oxygen saturation (SaO2) were seen, in patients with COPD, who performed weight -resisted upper limb exercises in water once a week with a twice weekly pulmonary rehabilitation programme (PRP) on land as opposed to a land-based PRP three times per week. Two of the included studies recorded improvement in the incremental shuttle walk test (ISWT) following exercise in water and one noted a greater improvement in the endurance shuttle walk test (ESWT) than in the ISWT after hydrotherapy. Maximal dynamic flexion showed marked improvement after an aquatic programme. Physical and cardiopulmonary improvements, including reduced levels of dyspnoea in some instances, were reported and these were linked to increased levels of physical conditioning, better QoL and improved ability to undertake ADL in the patients with COPD. Conclusion: Breathing exercises, where the patients exhale into the water, appear to have a beneficial effect on pulmonary outcomes particularly when the programme is of a duration of120 minutes per week or more and the exercise is performed on six days / week. The physical exercise hydrotherapy programmes address some of the muscular weaknesses resulting from the systemic effects of COPD. Both the cardiopulmonary benefits and physical benefits seem to result in a general improvement in the QoL of the patients and their greater ability to perform ADL. Social interaction and psychological well-being seem to be factors related to increased compliance in hydrotherapy exercise programmes when compared to compliance in land-based programmes. No information was retrieved from the included studies relating to the anti-inflammatory effects of hydrotherapy exercise programmes. No randomised controlled trials were sourced on the subject under review. The overall evidence was of variable quality, with three studies above average, two average and four below average, according to the LOW critical appraisal tool. From the results obtained in the review it became apparent that there is an urgent need for a number of randomised controlled trials to investigate the role of breathing exercises in combination with physical exercise programmes of hydrotherapy in the management of COPD so that this form of therapy can be utilised to its full capacity.

Introduction: There is a need for a health-related quality of life questionnaire in COPD that fulfills the advantages of both, generic and disease-specific questionnaires. Objective: To finalize the development of a new, hybrid questionnaire (disease-specific items supplemented with items from the SF-36), the McGill COPD Quality of Life Questionnaire and to evaluate its psychometric properties (reliability, validity, responsiveness) in COPD subjects. [...] / Introduction: Il y a nécessité d'avoir accès à un questionnaire de qualité de vie qui pourrait offrir les avantages d'un questionnaire générique et ceux d'un questionnaire spécifique à la MPOC. Objectif: Finaliser l'élaboration d'un nouveau questionnaire hybride le 'McGill COPD Quality of Life Questionnaire' (éléments spécifiques à la maladie complémentés d'éléments génériques issus du SF-36) et évaluer ses propriétés psychométriques (fiabilité, validité, réponse au changement) chez les sujets atteint d'une MPOC. [...]

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Background: In chronic obstructive pulmonary disease (COPD), understanding the problem of poor patient participation in evidence-based self-management (SM) and pulmonary rehabilitation (PR) programmes (together referred to as SM support programmes) is critical. This thesis aimed to improve understanding of poor patient participation and retention in these programmes; how participation might be improved; and how might patients be better supported with their SM. Methods: Using the Medical Research Council guidance on complex interventions this thesis (1) quantified the 'actual' patient participation and completion rates; (2) explained, using theory, the factors that influenced participation in studies of SM support including the programmes among chronic disease and COPD patients; and (3) explored patient and expert stakeholders' perspectives on the reasons for non-participation in SM support programmes, how participation might be improved, how might patients be supported with their SM. Results: (1) Among 56 studies, high study participation rates and completion rates were seen however, the incomplete reporting of participant flow confused the problem of participation. (2) Among 31 studies, participation among patients with chronic disease including COPD was shown to be influenced by their 'attitude' and 'perceived social influence/subjective norms'; 'illness' and 'intervention perceptions'. (3) From 38 interviewees, besides patients' beliefs, non-participation was also influenced by resignation and denial of the illness; health systems; and programme organisational factors. Professionals building relationships and supporting patients with their SM alongside programme organisational improvements might encourage patient participation in SM and the programmes. Conclusions Patient participation is a complex behaviour, besides socio-behavioural factors, participation behaviour can by influenced by a mix of several health system and programme organisational factors. Changing the behaviour of health professionals and indeed the wider health system, towards normalising a patient partnership approach, with implementation of SM support in routine care might help more patients to consider participation in their care and improve patient participation in COPD SM support programmes.

Significant cardiovascular morbidity and mortality exists in chronic obstructive pulmonary disease independent of traditional risk factors. A number of different hypotheses exist to explain this association including the contribution arterial stiffness and lung hyperinflation. Non-invasive cardiovascular imaging and assessment are ideal methods through which this relationship can be further studied although a number of the techniques have yet to be validated in COPD. In this thesis we aimed to achieve a number of goals. First, we aimed to assess the reproducibility and level of agreement between different measures of arterial stiffness in stable hyperinflated COPD. Second, we hoped to establish the utility of 3 different measurement techniques for measuring intrinsic cardiac function in stable hyperinflated COPD. Third, in a case-control study we compared surrogates of cardiovascular risk in hyperinflated COPD patients and a group matched for cardiovascular risk with normal lung function. Finally, we sought to understand the impact of pharmacologically reducing lung hyperinflation on cardiovascular structure, function and arterial stiffness. We have firstly demonstrated that non-invasive measures of arterial stiffness are reproducible in stable hyperinflated COPD. Secondly, we have established the level of agreement and reproducibility of three different CMR techniques for measuring intrinsic myocardial function which will provide important information for the powering of future CMR studies in COPD. Thirdly, we have shown that surrogates for cardiovascular outcomes are adversely affected in COPD compared to a group matched for global cardiovascular risk, suggesting that current scoring systems may be suboptimal in risk prediction in COPD. Finally, we have demonstrated that pharmacological lung deflation has consistent and physiologically plausible beneficial effects on cardiac structure, function and the pulmonary vasculature. Whether intrinsic myocardial function can be modulated through prolonged periods of lung deflation is as yet unverified and should be the focus of future clinical trials.

CoordenaÃÃo de AperfeÃoamento de Pessoal de NÃvel Superior / Chronic obstructive pulmonary disease is a common, avoidable and treatable disease characterized by persistent obstruction of the airways and lungs. This disease is usually progressive and associated with a chronic inflammatory response set off by noxious particles or gases. Patients with chronic obstructive pulmonary disease, represents a great impact on the increase of clinical care, as well as the economic health spending to provide better quality of life. This study characterizes the pharmacoepidemiological profile, adherence to drug therapy, pharmacotherapy complexity and performance of using inhalation devices in outpatientâs subjects of a referral hospital for treatment of pulmonary diseases. This is a descriptive, exploratory and transversal study. 83 individuals were interviewed, with a predominance of males, a mean age of 68.22 years, and low schooling. The average number of medications per patient was 5.58, characterizing the polypharmacy, and 81.9% had some type of comorbidity. The founded prevalence was mean adherence rate (45.8%). The most frequent response among the questions asked to measure adherence was related to forgettings (38.6%). The complexity therapy had a mean value of 15.9 points, a high score that reveals the difficulties in following the treatment. After evaluation of inhalation devices was found that as the use of dry powder inhaler Aerolizer, the technique was considered good in 62.5% of patients, the use of Respimat  inhaler was "good" in 70.96% of cases and the use of metered-dose aerosol showed to be regular in 64.7%. The evaluation of the use of the devices found flaws in several steps considered essential for their proper management. From these data, are needed strategies that aimed at enhancing actions to improve adherence to therapy and ongoing evaluation of inhalation devices, minimizing complications for the patient. / A DoenÃa pulmonar obstrutiva crÃnica, à uma doenÃa comum, evitÃvel e tratÃvel, caracterizada por obstruÃÃo persistente das vias aÃreas e dos pulmÃes, geralmente progressiva e associada a uma resposta inflamatÃria crÃnica desencadeada por partÃculas ou gases nocivos. Os pacientes portadores de DoenÃa pulmonar obstrutiva crÃnica representam um grande impacto no aumento dos atendimentos clÃnicos, assim como nos gastos econÃmicos com a saÃde para proporcionar melhor qualidade de vida. Este trabalho caracteriza o perfil farmacoepidemiolÃgico, a adesÃo à terapia medicamentosa, complexidade da farmacoterapia e o desempenho do uso de dispositivos inalatÃrios em indivÃduos atendidos em um ambulatÃrio de um hospital de referÃncia em tratamento de doenÃas pulmonares. Trata-se de um estudo descritivo, exploratÃrio e transversal. Foram entrevistados 83 indivÃduos, com predominÃncia do sexo masculino, idade mÃdia de 68,22 anos e baixa escolaridade. A mÃdia do nÃmero de medicamentos por paciente foi de 5,58, caracterizando a polifarmÃcia, e 81,9% tinham algum tipo de comorbidade. A prevalÃncia encontrada foi de mÃdia adesÃo (45,8%). A resposta mais frequente entre as perguntas realizadas para mensurar a adesÃo foi a referente aos esquecimentos dos pacientes em tomarem seus medicamentos diariamente (38,6%). A complexidade terapÃutica teve valor mÃdio de 15,9 pontos, um escore elevado que revela as dificuldades existentes no seguimento do tratamento. ApÃs avaliaÃÃo dos dispositivos inalatÃrios constatou-se que quanto ao uso de inaladores de pà seco Aerolizer a tÃcnica foi considerada boa em 62,5% dos pacientes, o uso de inalador Respimat foi âbomâ em 70,96% dos casos e o uso de aerossol dosimetrado mostrou-se regular em 64,7%. A avaliaÃÃo do uso dos dispositivos encontrou falhas em vÃrias etapas consideradas essenciais para o seu manejo adequado. A partir destes dados, se fazem necessÃrias estratÃgias que visem potencializar aÃÃes para melhorar a adesÃo à terapia e uma avaliaÃÃo contÃnua do uso dos dispositivos inalatÃrios, minimizando complicaÃÃes para o paciente.

Masters of Science in Medicine / The relationship between COPD and laryngopharyngeal sensitivity has not been previously determined. Limited research into the relationship between COPD and swallow function suggests that patients with COPD are at increased risk of aspiration. One possible mechanism for this is a reduction in laryngopharyngeal sensitivity (LPS). Reduced laryngopharyngeal sensitivity (LPS) has been associated with an increased risk of aspiration in pathologies such as stroke, however impaired LPS has not been examined with respect to aspiration risk in COPD. The Aims of this study were to investigate the effect of COPD on laryngopharyngeal sensation using Laryngopharyngeal Sensory Discrimination Testing (LPSDT) and to determine whether a relationship between LPS and swallow function in patients with proven COPD exists. Method: 20 patients with proven COPD and 11 control subjects underwent LPSDT utilising an air-pulse stimulator (Pentax AP4000) via a nasendoscope (Pentax FNL10AP). The threshold of laryngopharyngeal sensation was measured by the air pressure required to elicit the laryngeal adductor reflex (LAR). A number of further examinations were also completed for COPD subjects. These included respiratory function testing, self-reporting questionnaire on swallowing ability (SSQ), bedside clinical examination of swallowing (MASA) and endoscopic assessment of swallowing (EAS). Results: subjects with COPD had a significantly higher LAR threshold when compared to their normal healthy counterparts (p<0.001). Positive correlations were identified for the relationships between MASA score and EAS results for presence of laryngeal penetration / aspiration (p<0.04), vallecular residue (p<0.01) and piriform residue (p<0.01). Conclusion: Patients with COPD have significantly reduced mechanosensitivity in the laryngopharynx. Patients with COPD also have impaired swallow function characterised primarily by pharyngeal stasis. These changes may place patients with COPD at increased risk of aspiration.